skip to main content

Acute Charcot arthropathy — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

HardAnkle and FootAcute Charcot arthropathyMSRA

A 59-year-old man with type 2 diabetes, established peripheral sensory neuropathy and CKD G4 attends urgent primary care with a 36-hour history of a warm, swollen left midfoot. He recalls slightly twisting the foot when stepping off a kerb 3 days ago but continued walking without significant pain. He is afebrile and systemically well. The left foot is erythematous, diffusely swollen and 4°C warmer than the right. Skin is intact, with no ulceration, discharge or fluctuance. Pedal pulses are palpable and capillary refill is normal. There is no focal bony tenderness. CRP and white cell count are within reference ranges. Non-weight-bearing foot radiographs performed yesterday show no fracture or dislocation. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Keep him non-weight-bearing, arrange weight-bearing foot and ankle radiographs, and refer within 1 working day to the multidisciplinary foot care service

Explanation lettering: D = shown as C · E = shown as D · C = shown as E

This presentation is acute Charcot arthropathy until proved otherwise. The key discriminators are a unilateral hot, red, swollen foot with intact skin, relatively little pain despite marked inflammation, established sensory neuropathy and advanced renal impairment. Minor trauma is common, but may be unnoticed. Normal inflammatory markers and normal non-weight-bearing radiographs do not exclude acute Charcot arthropathy. NICE advises immediate non-weight-bearing treatment while diagnostic assessment is arranged, referral to the multidisciplinary foot care service within 1 working day (for triage within a further working day), and weight-bearing radiographs of the affected foot and ankle. MRI is considered if radiographs are normal but clinical suspicion persists; it should not delay offloading or referral. A is initially plausible because erythema and warmth suggest cellulitis, but there is no skin portal, ulcer, purulence or systemic illness, and Charcot is specifically an alternative explanation in this setting. B risks continued microtrauma and structural collapse; it would be appropriate for a simple soft-tissue injury after Charcot had been excluded. D identifies a useful second-line investigation but reverses the required sequence. E is inadequate because suspected acute Charcot is an active diabetic foot problem requiring urgent multidisciplinary assessment rather than routine preventive care.

Reference: NICE NG19: Diabetic foot problems: prevention and management — Recommendations, section 1.7 Charcot arthropathy (Published 2015; last updated 2019) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations NICE NG19: Diabetic foot problems: prevention and management — Recommendation 1.7.3 (Published 2015; last updated 2019) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations NICE NG19: Diabetic foot problems: prevention and management — Recommendation 1.7.4 (Published 2015; last updated 2019) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations